Two GOP senators are likely “no” votes: Kentucky’s Rand Paul and Maine’s Susan Collins. But Arizona’s John McCain, who spoiled this summer’s attempt at ObamaCare repeal, seems unlikely to repeat his performance and sandbag his good friend Lindsey Graham. That means the 50th vote will come down to Alaska’s Lisa Murkowski, who says she’s still trying to decide how the bill will affect her state. If Ms. Murkowski is honest with her constituents—and about her numbers—Alaska needs a “yes” vote.

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As the Graham-Cassidy (Heller-Johnson) health care bill appears to achieve a rapid intensification of support, so too have lies and exaggerations about its contents. Some people are very mistrustful about the states’ willingness and ability to provide a regulatory environment in which broad segments of society will have decent health care. The competency and motivation of the states needs to be compared not to some fantasy federal government with unlimited resources, constant benevolence and technical competence, but to a federal government that in fact is deeply in debt and that has proven itself inept at creating stable health insurance markets.

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The ACA spends more than twice as much on expanding Medicaid as it does on premium tax credits for the exchange. By consolidating funding for both entitlements, Graham-Cassidy allows states to pool resources to increase the attractiveness and stability of the individual market. In doing this, it meets a clear need, but it also facilitates more thorough reform by repealing the individual mandate and potentially allowing fairly priced, fully competitive insurance to be offered outside of the exchanges. It also greatly expands the flexibility and potential uses of Health Savings Accounts. France presses Trump to reconsider climate deal
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The idea of turning more power over to the states has long been advocated by conservatives, but there are compelling reasons for liberals to get behind devolving power from the federal government.

When Congress passed the Affordable Care Act in 2010, it left many of the details to the discretion of the Department of Health and Human Services, giving vast powers to the secretary to determine everything from fast-food menu labeling requirements to when individuals could purchase insurance. During the Obama years, the administration used its regulatory discretion — pushing and arguably exceeding the limits of the law — to prop up the president’s signature legislative accomplishment as the program ran into implementation problems.

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Cassidy-Graham has an important, albeit fixable, flaw—what we might call “asymmetric federalism.” The core idea in the bill is to take the money Obamacare spends on expanding coverage to the uninsured and give it to state governments in the form of block grants. States, in turn, could use these block grants to address the health-care needs of their populations. It’s an attractive idea, in theory. But the bill would put a heavy Washington hand on the federalism steering wheel. It would make it relatively easy for blue states to expand the role of single-payer health care, while making it rather difficult for red states to achieve market-oriented reforms.

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Senate Republicans’ last-ditch attempt to repeal and replace Obamacare rests on the unlikely collaboration of a veteran senator who can’t stand health policy, a wonky freshman who has never passed major legislation and a former senator who lost his seat a decade ago.

Together, Sens. Lindsey Graham (R-S.C.), Bill Cassidy (R-La.) and former Pennsylvania Sen. Rick Santorum crafted the latest GOP repeal bill in hopes of delivering on the party’s seven-year-old campaign promise to repeal Obamacare.

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Interestingly, while trying to craft legislation that would appeal to Republican moderates in the Senate, Cassidy and Graham have created a plan that is in some ways more conservative than the earlier House and Senate repeal-and-replace bills. The Cassidy-Graham bill is comparatively simple and straightforward. It lets states run their insurance markets as they see fit. This is a welcome return to federalist principles that the GOP had forgotten when crafting their earlier ObamaCare replacement bills.

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A crucial GOP senator says that after weeks of effort, there’s not enough agreement among lawmakers to advance a small package of bipartisan changes that would stabilize Obamacare’s health insurance markets. “We have worked hard and in good faith, but have not found the necessary consensus among Republicans and Democrats to put a bill in the Senate leaders’ hands that could be enacted,” said Senator Lamar Alexander, the Tennessee Republican who leads the Health, Education, Labor and Pensions committee.

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The Centers for Medicare and Medicaid Services has a powerful tool for improving quality and reducing costs: the Center for Medicare and Medicaid Innovation. Congress created the Innovation Center in 2010 to test new approaches or “models” to pay for and deliver health care. The complexity of many of the current models might have encouraged consolidation within the health care system, leading to fewer choices for patients. The Trump administration is analyzing all Innovation Center models to determine what is working and should continue, and what isn’t and shouldn’t. Strengthening Medicare and Medicaid will require health care providers to compete for patients in a free and dynamic market, creating incentives to increase quality and reduce costs.

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It’s worth reading the Graham-Cassidy bill. It would repeal the individual and employer mandates of the Affordable Care Act, impose per capita caps on Medicaid, increase contributions to health-savings accounts, allow states to waive regulations on private insurance providers, and provide those states with block grants so they can design their own health-care systems.

If the bill became law, it would therefore be a genuine federalist triumph. A large portion of the federal money now set to fund the Medicaid expansion and subsidies of the Affordable Care Act would be instead distributed to individual states. Each state would have the freedom and means to develop its own health-care system. Reasonable people disagree over how best to design a health-care system, and under Graham-Cassidy, their ideas could be tested without causing a nationwide catastrophe and the disruption of a vital service.
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